ABSITE Review - Biliary

Question 1

What are the borders of the triangle of Calot?

Answer 1

Cystic duct (lateral), CBD (medial), liver (superior)

Question 2

What is the blood supply of the CBD?

Answer 2

Right hepatic (lateral) and retroduodenal branches of the GDA (medial) supply to the hepatic and CBD (9- and 3-o’clock positions when performing ERCP)

Question 3

Which layer wall is not present in the gallbladder?

Answer 3

No submucosa

Question 4

What are the normal sizes of the CBD, GB wall and pancreatic duct?

Answer 4

CBD < 8mm (< 4mm

Pancreatic duct < 4mm

Question 5

Where is the highest concentration of CCK and secretin?

Answer 5

Duodenum

Question 6

What is the biliary duct that can leak after a cholecystectomy?

Answer 6

Duct of Luschka

Question 7

What increases bile excretion?

Answer 7

CCK, secretin, vagal input

Question 8

What decreases bile excretion?

Answer 8

VIP, somatostatin, sympathetic stimulation

Question 9

What is the function of the gallbladder?

Answer 9

Forms concentrated bile by active resorption of Na and water

Question 10

Where occurs the active resorption of conjugated bile acids?

Answer 10

Terminal ileum (50%)

Question 11

Where occurs the passive resorption of unconjugated bile acids?

Answer 11

Small intestine (45%) and colon (5%)

Question 12

What give the stool the brown color?

Answer 12

Stercobilin - breakdown product of conjugated bilirubin in gut

Question 13

What give the urine the yellow color?

Answer 13

Urobilin - breakdown product of conjugated bilirubin in gut; some gets reabsorbed and released in urine

Question 14

What is the rate-limiting step enzyme in cholesterol synthesis?

Answer 14

HMG CoA reductase

Question 15

What is the cause of stones in obese vs thin people?

Answer 15

Obese - overactive HMG-CoA reductase

Thin - underactive 7-alpha-hydroxylase

Question 16

What is the MC type of gallstone in USA? What is the cause?

Answer 16

Nonpigmented stones (75%)
Increase cholesterol insolubilization - caused by stasis, Ca nucleation by mucin glycoproteins, and increase water reabsorption from gallbladder

Question 17

What is the MC type of gallstone worldwide?

Answer 17

Pigmented stones

Caused by solubilization of unconjugated bilirubin with precipitation of Ca bilirubinate and insoluble salts

Question 18

What is the usual cause of black stones?

Answer 18

Hemolytic disorders or cirrhosis, chronic TPN or pts with ilea resection

Question 19

What are important factors for the development of black stones?

Answer 19

Increase bilirubin load, decrease hepatic function and bile stasis

Question 20

What are the stones primarily formed in the CBD? What is the MCC?

Answer 20

Brown stones

MCC - Infection causing deconjugation of bilirubin- E. coli

Question 21

What is Murphy’s sign?

Answer 21

Patient resists deep inspiration with deep palpation to the RUQ secondary to pain

Question 22

What are the 3 MC organisms in cholecystitis?

Answer 22

E.coli, Klebsiella, Enterococcus

Question 23

What are the risk factors for stones?

Answer 23

age > 40, female, obesity, pregnancy, rapid weight loss, vagotomy, TPN (pigmented stones), ileal resection (pigmented stones)

Question 24

What are the US findings suggestive of acute cholecystitis?

Answer 24

Gallstones, GB thickening (>4mm), pericholecystic fluid

Question 25

What is a HIDA scan? What is the interpretation of the results?

Answer 25

Technetium taken up by liver and excreted in the biliary tract. If gallbladder cannot be seen, it is secondary to cystic duct obstruction by stone --> cholecytitis If < 40% of GB volume excreted after CCK over 1 hour --> biliary dyskenesia

Question 26

What is emphysematous GB disease? What is the treatment?

Answer 26

Gas in GB wall, usually secondary to C. perfringens, high in diabetics Tx - Emergent cholecystectomy

Question 27

What is the MCC of gallstone ileus? What is the treatment?

Answer 27

Fistula between gallbladder and second portion of duodenum that releases stone, causing small bowel obstruction; elderly Tx - Remove stone with enterotomy proximal to obstruction; perform cholecystectomy and fistula resection if pt can tolerate it

Question 28

What is the definitive managment of a CBD intraoperative injury based on size?

Answer 28

If <50% the circumference of the CBD, can probably perform primary repair; in all other cases, will likely need hepaticojejunostomy or choledochojejunostomy

Question 29

What is the MCC of late postoperative biliary strictures?

Answer 29

Ischemia

Question 30

What is the treatment for early (7days) CBD injuries?

Answer 30

Early - Hepaticojejunostomy | Late - Hepaticojejunostomy in 6-8 weeks

Question 31

What is hemobilia and what are some of the symptoms?

Answer 31

Fistula between bile duct and hepatic arterial system | Sx - UGI bleed, jaundice, RUQ pain

Question 32

What is the MC malignancy of the biliary tract? Where the the MC site for metastasis?

Answer 32

GB adenocarcinoma | Noncontiguos liver metastases

Question 33

What is the risk of GB cancer in a patient with porcelain gallbladder?

Answer 33

10-20%

Question 34

What are the different stages of gallbladder cancer and respective treatment?

Answer 34

Stage I - limited to mucosa - laparoscopic vs open cholecystectomy Stage II - into the muscle - Wide resection at liver bed at segments IV and V (2-3cm margins), regional lymphadenectomy 90% present in Stage IV Laparoscopic approach contraindicated

Question 35

What are the risk factors for bile duct cancer?

Answer 35

C. sinensis infectio, typhoid, UC, choledochal cysts, sclerosing cholangitis, congenital hepatic fibrosis, chronic bile duct infection

Question 36

Which is the MC type for bile duct cancer and treatment?

Answer 36

Klastkin tumor - Upper 1/3 --> worst prognosis | Can try lobectomy and stenting of contralateral bile duct if localizedto either lobe

Question 37

What are the other types for bile duct cancer and treatment?

Answer 37

Middle 1/3 - hepaticojejunostomy | Lower 1/3 - Whipple

Question 38

What is the MC choledochal cyst?

Answer 38

Type I - fusiform or saccular dilatation of extrahepatic ducts (very dilated)

Question 39

What is the cause of choledochal cysts?

Answer 39

Abnormal reflux of pancreatic enzymes during development secondary to bad angle of insertion

Question 40

What is the treatment for a choledochal cyst?

Answer 40

Cyst excision with hepaticojejunostomy and cholecystectomy

Question 41

What are other types of choledochal cysts?

Answer 41

Type IV - partially intrahepatic | Type V - Caroli's disease - totally intrahepatic --> will need liver resection

Question 42

What happens in patients with UC and primary sclerosing cholangitis afte a colon resection?

Answer 42

Primary sclerosing cholangitis does not get better

Question 43

What is the long term treatment of primary sclerosing cholangitis? Why?

Answer 43

Liver transplant PSC leads to portal HTN and hepatic failure (scarring and patching with progressive fibrosis of intrahepatic and extrahepatic ducts

Question 44

What antibodies are present in primary biliary cirrhosis?

Answer 44

Antimitochondrial antibodies

Question 45

What is the Charcot's triad?

Answer 45

RUQ pain, fever, jaundice

Question 46

What is the Reynold's pentad?

Answer 46

Charcot's triad + AMS + shock

Question 47

What is adenomyomatosis?

Answer 47

Thickened nodule of mucosa and muscle associated with Rokitansky-Aschoff sinus - Not premalignant.

Question 48

What is a granunar cell myoblastoma?

Answer 48

Benign neuroectoderm tumor of gallbladder

Question 49

What size of gallbladder polyp is worrisome for malignancy?

Answer 49

>1cm

Question 50

What is Mirizzi syndrome?

Answer 50

Compression of the common hepatic duct by a stone in the infundibulum of the gallbladder or inflammation arising from the gallbladder or cystic duct extending to the contiguous hepatic duct, causing stricture and heaptic duct obstruction

Question 51

What are indications for asymptomatic cholecystectomy?

Answer 51

Patients undergoing liver transplant or gastric bypass procedure